Note: Javascript is disabled or is not supported by your browser. For this reason, some items on this page will be unavailable. For more information about this message, please visit this page: About CDC.gov.

Abstract

Introduction
Recent legislation requires schools to provide free drinking water in food
service areas (FSAs). Our objective was to describe access to water at baseline
and student water intake in school FSAs and to examine barriers to and
strategies for implementation of drinking water requirements.

Methods
We randomly sampled 24 California Bay Area public schools. We interviewed 1
administrator per school to assess knowledge of water legislation and barriers
to and ideas for policy implementation. We observed water access and students’
intake of free water in school FSAs. Wellness policies were examined for
language about water in FSAs.

Results
Fourteen of 24 schools offered free water in FSAs; 10 offered water via
fountains, and 4 provided water through a nonfountain source. Four percent of
students drank free water at lunch; intake at elementary schools (11%) was
higher than at middle or junior high schools (6%) and high schools (1%). In
secondary schools when water was provided by a nonfountain source, the
percentage of students who drank free water doubled. Barriers to implementation
of water requirements included lack of knowledge of legislation, cost, and other
pressing academic concerns. No wellness policies included language about water
in FSAs.

Conclusion
Approximately half of schools offered free water in FSAs before implementation
of drinking water requirements, and most met requirements through a fountain.
Only 1 in 25 students drank free water in FSAs. Although schools can meet
regulations through installation of fountains, more appealing water delivery
systems may be necessary to increase students’ water intake at mealtimes.

Introduction

Growing research implicates sugar-sweetened beverages (SSBs) such as sodas
and sports drinks as a contributor to rising obesity rates (1-3). Nationally,
80% of children aged 2 to 19 years consume at least 1 SSB daily (4). Policy
makers have responded with legislation to restrict sales of unhealthy beverages
in schools (5). However, less emphasis has focused on improving consumption of
healthy alternatives, namely water.

Substituting water for SSBs can result in an average decrease of 235 calories
per day (6) and can also prevent obesity (7-10). In a randomized controlled
trial of German elementary schools, installation of filtered, refrigerated
fountains, distribution of reusable water bottles, and promotion of water intake
through education decreased the risk of overweight among intervention study
participants (9).

In September 2010, California enacted SB 1413, legislation requiring schools
to provide access to free drinking water during mealtimes in school food service
areas (FSAs), locations where meals are served or eaten, by July 1, 2011 (11).
In December 2010, the President signed the Healthy, Hunger-Free Kids Act of 2010
(Act), which included a similar provision requiring access to free drinking
water in US public schools where meals are served (12).

To our knowledge, no data have been published regarding water access in
school FSAs, and such information would be useful to schools seeking to
implement new water requirements. The objective of this study was to use school
observations to document provision of water and student water consumption
patterns in FSAs in a sample of California Bay Area schools. Secondary
objectives were to document barriers to water provision in schools and to
identify innovative water consumption promotion practices in schools.

Methods

Study participants

We collected data from January to May 2011 before implementation of SB 1413
and the Act. We selected public schools from the National Center for Education
Statistics’ Common Core of Data (CCD) (13). The 1,313 standard California public
schools (excluding private, K-8 or K-12, special educational, vocational, and
alternative schools) were from California’s Bay Area region (Alameda, Contra
Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma
counties). To understand water provision in schools of varying type and
location, we stratified eligible schools by CCD urban-centric locale and school
type. We collapsed locales (large, midsize, or small cities; large, midsize, or
small suburbs; fringe, distant, or remote towns; and fringe, distant, or remote
rural areas) into 4 categories: city, suburb, town, and rural area. In these
categories, we further stratified schools by primary, middle, and high school to
generate 12 separate sampling strata (eg, city high, city middle, rural
elementary). Using a random number generator, we generated a random list of all
eligible California schools for each of the 12 strata.

Instruments

We developed a telephone survey and observational tool to assess provision of
drinking water and policies and practices related to school drinking water on
the basis of a literature review, a previous qualitative study conducted by the
first author (A.I.P.) on access to school drinking water (14), and feedback from
study collaborators. To improve the content validity of the survey and
observational tool, we used a snowball sampling approach to identify 15 experts
with content knowledge of drinking water access and policies and practices
related to drinking water access in schools. We used these experts’ comments to
revise the survey and observational tool, which we then pilot tested with 10
staff from ineligible schools (ie, located outside of the Bay Area or
nonstandard public schools).

The observational tool assessed the following domains: free drinking water
access and quality, student drinking water intake in FSAs, and bottled water and
other beverages available for purchase. We also reviewed school documents to
assess school drinking water policies.

Observers assessed student intake of water in FSAs by counting the number of
students who drank free drinking water in the FSA during all lunch periods on an
observation day. Although students may eat lunch in locations throughout the
campus, it is impractical to ensure that drinking water is accessible in all of
these locations. For these reasons, we defined an FSA as an area within 100 feet
of where reimbursable meals were served. The water source observed was the one
closest to the FSA. We estimated the percentage of students observed drinking
water at lunch by dividing the number of students observed drinking water at
lunch by the daily attendance.

Observers also recorded the type, location, and cost of beverages provided
with the school lunch and available for purchase. After the visit, we obtained
wellness policies from each participating school’s district for analyses of
language regarding drinking water provision.

The school administrator survey measured drinking water availability (ie,
type, location, and source), drinking water policies and practices (eg, quality
and fountain accessibility or maintenance), and barriers (eg, cost, policies and
contracts, student behavior) to school drinking water access. We obtained school
sociodemographic data from the Education Data Partnership (15).

Data collection procedures

We mailed an invitation letter to principals of eligible schools. A research
assistant (RA) then contacted study participants to confirm receipt of
materials, answer questions, and schedule an interview time. RAs contacted
potential study participants until they declined. If a school declined, we
sampled the next randomly chosen school from the study stratum. To obtain our
goal sample size of 24 schools, we had to contact 44 schools from the overall
sampling frame of randomly selected California schools. We obtained consent from
survey respondents (eg, school principals, school administrators) before
collecting data.

RAs or the first author (A.I.P.) conducted all surveys. We audio recorded
surveys, which lasted 10 to 20 minutes. After conducting the surveys, RAs
scheduled an observational visit. Each RA had extensive training using the
observational protocol before data collection; 2 RAs and the principal
investigator (A.I.P.) visited schools until consistency in coding was achieved
(κ > 0.80) for all variables. Thereafter, 2 RAs visited each school and
simultaneously coded all observational data on paper checklists. Kappa
statistics ranged from 0.88 to 1.0 for observational variables, indicating
excellent interobserver reliability.

We provided study participants with $50 gift cards for participation.
University of California, San Francisco’s Committee on Human Research approved
the study.

Data analysis

We analyzed data using Stata version 11 (StataCorp LP, College Station,
Texas). We used descriptive statistics (frequencies, percentages, and means) to
summarize school characteristics (ie, school population, racial/ethnic
breakdown, percentage of students eligible for free and reduced-price meals
through the National School Lunch Program [NSLP]), and main study outcomes (eg,
drinking water availability in FSAs and students’ water intake). We used t
tests and χ2 tests to assess the differences between study
participants and nonparticipants.

Results

Our response rate was 55%. Of schools that declined (n = 20), 13 declined due
to lack of time, 5 stated no reason for declining, and 2 declined due to lack of
interest. Participating schools did not differ significantly from schools that
declined in terms of school type, urban-centric locale, mean student enrollment,
percentage of students who qualified for free or reduced-price meals, student
race/ethnicity, or percentage of English learners (Table
1). Sociodemographic characteristics of study schools were similar to those
of Bay Area schools in aggregate. Of the 24 administrators who participated, 16
were principals, 3 were assistant principals, and 5 were “other.”

Beverages available in food service areas

Of the 14 schools that offered free drinking water in FSAs, 10 offered water
via fountains, while the remaining schools had an alternative delivery system (Table
2). Beverages most commonly offered with the NSLP included 1%/skim
unflavored and flavored milk; 100% juice and bottled water were offered in some
schools. Only 1 elementary school offered competitive beverages or beverages for
purchase in the FSA. In secondary schools, the most commonly available
competitive beverages were bottled water and sports drinks. The mean price of
bottled water in FSAs was $0.92 per bottle. Despite legislation (Senate Bill
965) that since 2009 has prohibited the sale of SSBs other than sports drinks in
California public schools, 1 school offered “slushies,” a frozen flavored
beverage.

Student water intake in food service areas

At schools with free water in FSAs, only 4% of the 11,226 students in daily
attendance were observed drinking free water at lunch. The percentage was
highest in elementary schools, followed by middle and then high schools (Figure
1). In the schools that did provide water in FSAs, most provided water of good
overall quality; the mean water temperature was cold (1.9), the mean water
clarity was clear (1), mean water flow was of medium strength (1.8), and mean
cleanliness of the water delivery system was very clean to clean (1.6). Only 1
school dispensed water that was not cold or very cold and only 2 schools
dispensed water of low or no strength. Although all water delivery systems in
school FSAs were described as clean, 2 fountains contained gum and 1 fountain
contained a small amount of dirt.

Figure 1. Percentage of students (n = 11,226) observed
drinking free water at lunch, by school type and water delivery system, Bay
Area, California, 2011. The percentage of students drinking water at lunch was
obtained by counting the number of students who drank water in the food service
area divided by the total daily student attendance. There were no nonfountain
sources of drinking water in primary schools. The percentage of middle school
students who drank water from a fountain source was significantly lower than the
percentage of students who drank water from a nonfountain source (P =
.04). This difference was not significant among high school students (P =
.09). The percentage of students drinking water at lunch was higher when water
was available via a delivery system other than a drinking fountain (eg, water
dispenser with cups). [A tabular version of this figure is also available.]

Alternative drinking water sources in food service areas

We photographed alternative water delivery systems in school FSAs (Figure 2).
Only 4 schools, all secondary, offered water through a nonfountain source. One
high school purchased a dispenser that dispensed filtered hot and cold tap
water. According to the school, the dispenser was installed because no other
functional drinking water source was available in the school. A school
administrator estimated that the unit, paid for by the nonprofit organization
that operates the charter school, costs $200 to $400. Filter changes required
every few months were estimated as $20 per change. Students were expected to
bring their own container to access water from the dispenser. At this same
school, 1 student was selling a plastic foldable bisphenol A (BPA)–free water
bottle at the school as a fundraiser ($4 per bottle).

Figure 2. Alternative drinking water sources in Bay
Area, California, food service areas. Top left, a hot and cold water dispenser
found within 10 feet of where food was served in an indoor high school
cafeteria. Resting on the dispenser is a purple Vapur-brand foldable reusable
water bottle sold as a fundraiser by a student group at the school. Top right, a
hydration station located approximately 50 feet of where food was served in an
indoor high school cafeteria. Bottom left, a Cambro-brand cooler and foam cups
located within 5 feet of where food was served in an indoor middle school
cafeteria. Bottom right, an Igloo-brand cooler and Dixie-brand cups provided for
students outdoors within 5 feet of a food service window but approximately 100
feet from the main cafeteria in a middle school.

Another high school installed a hydration station with a mural backsplash
displaying promotional messages to encourage water intake. The hydration station
was installed by the food service director, a champion of health and nutrition.
The cost of the station, estimated at $2,000, was paid for through the food
services budget, which often covers ancillary costs (eg, trays, napkins)
associated with meal service. Students at this school, similar to the school
with a dispenser, were expected to bring their own containers for drinking water
due to concerns about waste (eg, cups) not being discarded appropriately in
trash receptacles.

School administrator perceptions regarding new school drinking
water requirements

Half (12 of 24) of school administrators had heard about the Act or SB 1413.
In our study, 14 schools had water in the FSA before implementation of SB 1413
and the Act. Of these 14 schools, 3 reported that they began providing water in
the FSA as a result of hearing about SB 1413. Administrators most commonly cited
more pressing academic concerns (n = 19) and the cost of new water programs (n =
16) as barriers to implementation of water requirements.

As a result of hearing about SB 1413, food services departments in 2 middle
schools filled water dispensers with ice water and provided water with
disposable cups at lunch. At both of these schools, dispensers were on hand at
the school, and food services absorbed the cost of cups. Per estimates, water
coolers cost approximately $30 each and cups are $0.02 to $0.05 each for 4- to
6-ounce foam cups and Dixie-brand cups.

Water language in school district wellness policies

Among wellness policies for the 20 school districts represented in our study
(4 schools were in duplicate districts), 11 included language related to
drinking water (Table 3), but
none specifically mentioned that free drinking water should be available in
FSAs. Three district wellness policies contained water-related language in more
than 1 thematic area (eg, water allowable as a competitive beverage, provision
of water with snacks). Only half of schools that offered water via a nonfountain
source had water-related language in their wellness policy.

Discussion

This study, conducted after enactment but before implementation of federal
and state requirements regarding water in FSAs and the first peer-reviewed study
to examine water access in school FSAs (16), demonstrated that nearly half of
schools did not have free water available in FSAs and that drinking fountains
were the most common water source.

Observations of students indicated that the percentage of students drinking
water in FSAs was higher in schools with younger children and among schools with
nonfountain sources of water. As suggested in previous studies, students may
choose not to drink from fountains because they perceive water from fountains as
unclean or unsafe to drink or because fountains have genuine problems (eg,
unclean, in disrepair, dispense unpalatable water, permit only small sips)
(14,17). Because fountains in this study were in good condition, we hypothesize
that low student intake of water from fountains may be due to student
preferences for other beverages or for water from alternative drinking water
delivery systems, rather than because of poor water quality. Previous studies
suggest that providing appealing water may increase student water intake (9,18).
Further understanding what types of water delivery systems are most appealing to
students of different ages is essential to increasing students’ water intake.

Tap water from a fountain was the most common source of free water available
in study school FSAs. Only a few schools offered free bottled water with meals.
In most secondary schools, bottled water was available as a competitive beverage
(19,20). The price of bottled water ($0.92 per bottle) could prevent students,
particularly those of lower socioeconomic status, from purchasing water at
school on a frequent enough basis to meet recommendations for adequate water
intake.

Given that a large number of schools did not have free water in FSAs before
the corresponding legislation went into effect, schools may need assistance in
meeting the requirements. A major barrier is a lack of knowledge of drinking
water requirements among school administrators. Although SB 1413 and the Act
passed in fall of 2010 and received media coverage, many administrators were not
aware of the legislation. One contributing factor could be that federal and
state and agencies (US Department of Agriculture, California Department of
Education) did not provide schools with guidance until April 2011 (21,22).
However, partnering with statewide associations of teachers, school nurses, as
well as school boards may be an effective strategy for disseminating legislative
information.

Because schools participating in federal child nutrition programs (eg, NSLP)
must implement school wellness policies, which include goals and action steps
for school-based activities that promote student wellness, such policies can be
leveraged to assist schools in improving FSA drinking water provision. In our
analysis, no wellness policies mentioned provision of free drinking water in
school FSAs and only 3 policies included language about drinking water provision
that encompassed more than 1 theme. No studies have examined wellness policies
for language regarding school FSA water access. A 2008–2009 national study of
school wellness policies showed that only 12% to 13% of schools had language
regarding free water availability throughout the school day (23). On the basis
of these limited studies, developing more comprehensive school wellness policy
language regarding water access may help improve drinking water access and
intake in schools (24).

However, having comprehensive water language in school wellness policies may
not be sufficient to ensure that safe and appealing drinking water is available
on school campuses. Ongoing implementation and monitoring is needed to ensure
continued access to free drinking water. As seen in this study, schools that
provided a nonfountain water source often had a “water champion” who was
essential to developing and sustaining drinking water programs. These champions,
who were all food service directors in this study, went beyond the letter of the
law to provide students with water that was more appealing than water provided
via a fountain. Prioritizing drinking water for school-level policy bodies such
as wellness committees or coordinated school health councils may help to
institutionalize such water champions. Because water is a topic that spans
multiple disciplines, parents, facilities managers, teachers, and food services
directors can all champion water in schools, preferably working together toward
achieving this shared aim.

This study has several limitations. Although the use of observations instead
of self-report is a strength, the observational methods limited the sample size
and confined the study to a single California region. Another limitation is the
poor response rate. Schools, in particular schools with poor drinking water
access, may have been hesitant to participate in the study because of the
observational component and the desire to remain inconspicuous. If this was the
case, water access in FSAs may be lower than that reported in this study. In
calculating the percentage of students who drank free water during mealtimes, we
used student daily attendance as the denominator. In some schools, particularly
high schools, students may have eaten meals off campus or in other areas of the
schools, so we may have underestimated student consumption of free water at
lunch. Finally, although in previous studies we examined students’ perspectives
regarding access to drinking water in schools (14,18), we did not do so in this
study.

Approximately half of schools had access to free drinking water in school
FSAs before implementation of drinking water requirements, and in such schools,
only 1 in 25 students drank the water. Increasing student water intake in
schools requires a multipronged approach, which includes not only environmental
changes (eg, installation of more appealing water delivery systems, such as
hydration stations or dispensers), but also the promotion to encourage intake of
water instead of SSBs.

Acknowledgments

This study was funded by the Robert Wood Johnson Foundation Healthy Eating
Research Program. Dr Patel was supported in part by grant no. KL2 RR024130 from
the National Center for Research Resources, National Institutes of Health (NIH),
and the Clinical Translational Sciences Institute, Office of the Director,
University of California, San Francisco. Dr Brindis was supported in part by
grants from the Maternal and Child Health Bureau, Health Resources and Services
Administration, US Department of Health and Human Services (nos. U45MC00002 and
U45MC00023). The views expressed in this article are solely those of the authors
and do not necessarily represent the official views of NIH or the Robert Wood
Johnson Foundation. The authors have no financial relationships or conflict of
interest to disclose.

Water availability during National School Lunch Program meal service. US
Department of Agriculture; 2011.
http://www.fns.usda.gov/cnd/governance/Policy-Memos/2011/SP28-2011_osr.pdf.
Accessed March 12, 2012.

Drinking water for students in schools. California Department of Education;
2011. http://www.cde.ca.gov/ls/nu/he/water.asp. Accessed March 12, 2012.

Tables

Table
1. Characteristics of Observation Schools Compared With Bay Area and California
Schoolsa,b

Characteristic

California Schools (n = 9,888)

Bay Area Schools (n = 1,747)

Observation Schools (n = 24)

Schools That Declined Participation (n = 20)

School type, n (%)

Elementary

5,736 (58)

1,030 (59)

8 (33)

6
(30)

Middle

1,305 (13)

245 (14)

8 (33)

7
(35)

High

1,264 (13)

227 (13)

8 (33)

7
(35)

School locale, n (%)

Rural

1,582 (16)

70 (4)

6
(25)

4
(20)

Town

890
(9)

35
(2)

6
(25)

2
(10)

Suburb

3,460 (35)

646 (37)

6 (25)

11
(55)

City

3,856 (39)

996 (57)

6 (25)

3
(15)

Student enrollment, mean no.

Elementary

530

475

385

519

Middle

810

741

687

682

High

1,402

1,247

1,644

1,481

Eligible for free or reduced-price meals, n (%)

3,404,790 (55)

382,353 (39)

8,254 (38)

6,936 (38)

APIc growth score

767

NA

801

804

Race/ethnicity, n (%)

African American

424,327 (7)

78,431 (8)

1,521 (7)

1,095 (6)

Latino

3,118,404 (50)

323,530 (33)

7,603 (35)

6,206 (34)

White

1,673,278 (27)

284,314 (29)

6,951 (32)

7,119 (39)

Asian/Pacific Islander

720,311 (12)

225,490 (23)

3,910 (18)

3,468 (19)

English learners, n (%)d

1,468,771 (24)

215,686 (22)

4,127 (19)

3,651 (20)

Abbreviation:
NA, not applicable.a Participating schools did not differ
statistically from schools that declined in terms of school type, urban-centric
locale, mean student enrollment, percentage of students who qualified for
free/reduced price meals, student race/ethnicity, or percentage of English
learners (P > .05).b Data obtained from Education Data
Partnership (15).c API refers to the Academic Performance Index,
a measure of academic performance in California schools based on standardized
testing. The score ranges from 200 to 1,000, with a target score of 800 for
California.d Students who report a primary language other than
English and who have been determined by the state of California to lack clearly
defined English language skills necessary to succeed in the school’s regular
instructional programs.

Table
2. Beverages Available in Observation Food Service Areas,a by School
Type (n = 24)

Beverage type

Elementary (n = 8)

Middle (n = 8)

High (n = 8)

Free water

Fountains

5

3

2

Otherb

0

2

2

Available via the National School Lunch Program

Bottled water

1

1

0

1%/Skim unflavored milk

8

8

8

2%/Whole unflavored milk

0

0

0

Flavored milk

5

6

7

100% Fruit juice

2

1

0

Competitive and for purchase

Bottled water

0

7

7

1%/Skim unflavored milk

0

0

0

2%/Whole unflavored milk

0

0

0

Flavored milk

0

0

1

100% Fruit juice

1

7

6

Sports drinks

0

6

5

Other sugar-sweetened beverages

0

0

1

Noncaloric drinks

0

0

1

a Food
service area refers to the area in which meals are served and/or eaten. When
schools allowed students to eat anywhere on campus we defined the food service
area as within 100 feet of the location where food was served.b
Other refers to sources of free water other than drinking fountains (eg, water
dispensers, bottled water, hydration stations, pitchers).

Table
3. Language Regarding Drinking Water Provision in Public School District
Wellness Policies, Bay Area, California

Water-Related Theme

No. of Districts With Theme

Example from Wellness Policy

Water without added sweeteners is allowable in schools as a competitive
beverage

10

From one-half hour before to one-half hour after the end of the school
day, the only beverages sold to pupils by any entity are: fruit- or
vegetable-based drinks of no less than 50% fruit or vegetable juice and
no added sweeteners; water with no added sweeteners; milk (2%, 1%,
nonfat, soy or rice, and other nondairy milk); or
electrolyte-replacement beverages containing no more than 42 grams of
sugar per 20-ounce serving.

Any student organization or organizations may be approved to sell
food at any time during the school day, including the regularly
scheduled food service period(s) as provided in 1) and/or 2) below:
only 1 such organization each school day selling no more than 3
types of food or beverage items such as healthy snacks, popcorn,
nuts, fruit, fruit juices, and water.

Marketing and promotion of healthful foods and beverages such as
water during the school day and at school-sponsored events and
activities

Healthy food and beverage choices (ie, fresh fruits and vegetables,
whole grains, low-fat dairy products, 100% fruit juice, and water)
will be promoted in all school activities and school-sponsored
events where food and beverages are offered or sold.

Emphasis on serving water with snacks at school

2

Snacks
served during the school day or in after-school care or enrichment
programs will make a positive contribution to children’s diets and
health, with an emphasis on serving fruits and vegetables as the
primary snacks and water as the primary beverage.

Request that donated drinks for parties and school events include
water

1

Schools will request that donated drinks (under any existing soda
contract, and brought in for class parties, school sponsored events,
etc) will be from the list below: water, 100% fruit juice or
fruit-based drinks with no less than 50% fruit juice and no added
sweetener, electrolyte-replacement beverages with no more than 42
grams of added sweetener per 20-ounce serving, and/or nonfat or
reduced fat milk.

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.